Hurst 9 Study Guide Exam Questions.
A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and
... [Show More] shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first?
1. Administer oxygen.
2. Obtain a blood pressure reading.
3. Connect to cardiac monitor.
4. Raise head of bed to 90 degrees. - CORRECT ANSWER 4. Correct: This is your priority. This position will facilitate maximum lung expansion. It will also decrease venous return to the right side of the heart so that pressure decreases in the pulmonary vascular system.
1. Incorrect: Oxygen is needed, but the first thing the nurse should do is raise the head of the bed, so the client can breathe easier. Then get the oxygen set up.
2. Incorrect: Obtaining a blood pressure reading at this point is delaying treatment. The problem is a breathing problem. Do something to fix the breathing problem first. Then, you can continue your assessment by checking circulation status.
3. Incorrect: Connecting the client to a cardiac monitor is an appropriate intervention, but facilitating breathing takes priority and should be done first.
Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform?
1. Instruct the client to drink at least 8 ounces of water.
2. Close room blinds to darken the environment.
3. Assist the client into a supine position in bed.
4. Notify primary healthcare provider of client's complaints.
Rationale
Strategies - CORRECT ANSWER 3. Correct: The most frequent cause of headache following a lumbar puncture is loss of, or leaking, of cerebrospinal fluid from the puncture site. Positioning a client is an important nursing responsibility, particularly in this situation since the supine position could help to stop any leaking. Following this, the nurse will pursue additional actions as ordered by the primary healthcare provider, which may include increasing fluids or even a blood patch.
1. Incorrect: Although increasing fluids may help clients under specific circumstances, it is not the priority action in this situation. Additionally, the primary healthcare provider may order IV fluids rather than PO fluids.
2. Incorrect: A darkened room can be beneficial for clients with severe migraine headaches, but would not be useful to this client. Headaches following a lumbar puncture are caused by the loss of cerebrospinal fluid and would not respond to a quiet, dark environment.
4. Incorrect: Although the primary healthcare provider should indeed be notified of this situation, the nurse's priority action should first focus on stabilizing the client by addressing the cause of this problem and positioning the client.
A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate?
1. Apply splint nightly to affected extremities.
2. Approach client from the right side.
3. Provide full range of motion once a shift.
4. Elevate left extremities on a pillow.
5. Place pillow in the right axilla.
6. Wrap affected hand into a fist. - CORRECT ANSWER 1., & 5. Correct: With a left-sided stroke, the right side of the body is affected. Applying a splint at night to the affected extremity will prevent flexion of that extremity. Prolonged flexion leads to contractures. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
2. Incorrect: Vision is controlled by the left side of the brain. Vision on the right side of both eyes may have decreased (hemianopia) due to this left-sided stroke, so approach the client from the left side.
3. Provide full range of motion four or five times a day to maintain joint mobility.
4. Incorrect: Remember, left-sided cerebrovascular accident = right sided paralysis. The right extremities, which are affected by the left-sided stroke should be elevate on a pillow to prevent dependent edema.
6. Incorrect: The fingers should be positioned so that they are minimally flexed. This will prevent a contracture of the hand. Flexing the fingers into a fist will cause them to contract. [Show Less]